Case Study: Fletcher Allen leverages EMR connectivity for optimized imaging

Chuck Podesta, senior vice president and CIO at 500-bed Fletcher Allen Health Care in Burlington, Vt., is dogged in his determination to use IT to improve care for patients across the state. Relatively small, Vermont's population is mostly rural and broadly scattered.

Fletcher Allen, an affiliate of the University of Vermont Medical School, is uniquely positioned. Other widely-scattered facilities often send patients to Fletcher Allen for tertiary - even, quaternary care. Podesta saw an unusual opportunity with regard to his relationship with his core EMR vendor, Verona, Wis.-based Epic Systems Corporation.

“Typically, Epic's market has been large academic medical centers and health systems and large medical practices; they haven't been that interested in smaller hospitals,” Podesta says. “And because we are the only academic medical center in Vermont, they've allowed us to extend our Epic product license to other hospitals in the state. I call it a ‘group-purchase, hosted' solution, because we host the single database,” he says.

Podesta and his colleagues have developed PRISM Regional, a core clinical information system whose capability extends throughout Vermont and across the border into the state of New York. The system has gone live at five of Vermont's 13 hospitals, as well two in upstate New York. In order to provide imaging access to hospitals throughout the region, the PRISM/Epic EMR is regionalizing imaging communications statewide, he says.

And this is true even though Fletcher Allen's RIS is the ImageCast product from GE Healthcare (Waukesha, Wis.) and its PACS is from McKesson Corporation (Alpharetta, Ga.), according to Podesta.

In terms of diagnostic imaging, Fletcher Allen's PRISM Regional initiative is improving clinicians' access to, and use of, diagnostic images as well as other clinical data in the broader context of clinical IT development. Any physician linked into the PRISM system can access any archived image by clicking on an icon on the main EMR screen and can launch the PACS Web viewer onscreen. And for patients in a state such as Vermont with low-density populations, improving such access inherently means improving patient care. In many cases, it can make the difference between an ambulance transfer and the ability to care for patients tele-medically, improving the speed and effectiveness of care.

In many cases, it can make the difference between an ambulance transfer and the ability to care for patients tele-medically, improving the speed and effectiveness of care.

“For example,” Podesta says, “often, a physician three hours away in a community hospital isn't sure whether to transfer a patient or not; and if the decision is being made during a telephone-based consult with a physician here, and the diagnostic images aren't available to the physicians in both facilities, then there can be uncertainty as to what to do. In that case, if you're not sure, you've got to transfer the patient. Then later on after the patient is transferred, sometimes you discover that the patient could, in fact, have stayed in the community hospital and not taken a three-hour ambulance ride, with the family driving behind.

“Now, with the ability of physicians in all the linked facilities to access those diagnostic images, the radiologist here at Fletcher Allen, and sometimes the ED physician here, can be on the phone with the ED physician at the outlying hospital, and all can be looking at the same set of images and come to a more optimal decision.” Podesta says it's more point-to-point than traditional teleradiology. “And in places like Vermont, New Hampshire, and upstate New York, this kind of technology has a huge impact, especially since the EMR is wrapped around everything.”

“We were very aggressive in terms of upgrading our infrastructure and our network, both inside the facilities and between and among them.”

Could this model of IT-supported care delivery be replicated elsewhere? Podesta says it's certainly a possibility, and Judith Faulkner, founder and CEO of Epic, agrees. “Actually, a few of our customers have extended their software to small neighboring hospitals over the past half-dozen years or so with our full support,” she says. Faulkner says Epic is set to release Sonnet, its inpatient EMR for smaller hospitals this month (an ambulatory version came onto the group practice market in the fall). In the meantime, Podesta and his colleagues will be busy for the next few years broadening and deepening the reach of their clinical information systems to further enhance care delivery across mostly rural Vermont.

Case Study: A strong integration focus takes hold in Nebraska

At Alegent Health, a 1,832-bed integrated delivery system in Omaha, Neb., Senior Vice President and CIO Ken Lawonn has been focusing on clinical IS integration for imaging management - RIS, PACS and EMR - for driving care delivery.

“We're pretty advanced in terms of imaging. We signed a deal with Siemens seven years ago,” he says, referring to Malvern, Pa.-based Siemens Medical Solutions, “one of whose major aspects was to standardize and upgrade our technology and to integrate our RIS/PACS solution.” The deal also called for Siemens to standardize and implement a number of modalities at Alegent, including a variety of MRIs, CTs, and a PET CT. The work has also included deploying Siemens' Syngo Workflow RIS, SIENET Enterprise PACS, as well as Syngo Dynamics Cardiology PACS. By November 2008, the organization was live with all the various functionalities.

As part of the broad initiative, Lawonn and his colleagues have standardized RIS and PACS capabilities and workflow across their seven-hospital system. The broad objective is to improve efficiency and clinician workflow for better patient care.

Lawonn says, among the returns on investment so far have been:

• A 55 percent decrease in overall turnaround time for radiology reports;

• Decreased turnaround time for surgical case images (from more than 9 minutes to less than 2 minutes, on average);

• Decreased patient lengths of stay;

• Improved consultation capabilities between radiologists and referring physicians;

• The “recapture” of physical space from former film libraries to space for imaging (at Mercy Hospital, a second CT was able to be installed in the space formerly occupied by the old film library);

• Elimination of 10.5 FTEs from management of the old film library at the organization's flagship hospital (most of these positions were replaced by the hiring of people for new positions, including a new systemwide PACS administrator and four radiology IT specialists).

The gains were made at a time of rapidly growing study volume, which leapt from less than 250,000 studies in 2004 to more than 310,000 in 2007. At the same time, cardiology imaging was also brought into the enterprise-wide integration initiative.

“This has all gone very well,” says Lawonn, who notes that moving forward on the system-wide initiative helped revolutionize radiologist workflow and operations. “We used to have three radiology groups that served our locations,” he says. “Now we have two; one that services one location, and one that services the other five. And all this integration has really helped them with workflow. They have two neuroradiologists who can service all the locations, who can read from one location.”

What's more, he says, “All diagnostic images and radiology results flow back to the EMR. So a study ordered in the EMR system is processed in the RIS/PACS, and the results are interpreted and brought back and stored in the EMR. It has a link, so that when referring physicians go into the record, they see the result. If they want to see an image, they can click on an icon, and launch into the PACS Web viewer.”

The imaging integration initiative is ongoing, Lawonn emphasizes, even as he takes pride in the improved connectivity, clinician workflow, and efficiency. Asked what the biggest lessons to date have been, he says one is the validation of his emphasis on infrastructure development at the outset. “One of the things that turned out to be a big plus for us was that we anticipated connectivity and bandwidth would be an issue once we implemented PACS,” he says. “So we were very aggressive in terms of upgrading our infrastructure and our network, both inside the facilities and between and among them. We didn't want the adoption or the use of the system to be hampered by the fact that we didn't have enough infrastructure.” Storage remains an ongoing challenge, but Lawonn feels the organization has laid a strong foundation for continual innovation.

Case Study: In the rural West, a community hospital system advances

In contrast to the situations at Alegent Health in Nebraska and Fletcher Allen Health Care in Vermont, the Roseville, Calif.-based Adventist Health system is comprised entirely of community hospitals, most of which are in smaller cities and towns, and in rural areas. What's more, only three of the system's 16 hospitals, spread out across California, Oregon, Washington, and Hawaii, are larger than 300 beds, while the majority are smaller than 200. Further, it is commonplace for patients to have been admitted to more than one Adventist hospital over time; and for Adventist clinicians to consult with one another over great distances. So the need for a unified image archive and an integrated clinical IS infrastructure has been a top goal of Alan Soderblom, Adventist's vice president and CIO, and Greg McGovern, the system's assistant vice president and CTO.

“I think our most significant area of progress has been the creation of a central archive for the images,” says Soderblom. “That then allows us to take the next step, which is the integration into the electronic health record, so that essentially, a physician on the floor can go into our Project Intellicare (Kansas City, Mo.-based Cerner) and pull up the image from that system rather than going to a separate PACS system. So it provides more ease of access to that image.” (Adventist has implemented Cerner's core EMR across its entire system, as well as Cerner's Cedara RIS product system-wide, while its hospitals use GE's PACS product.)

The central image archive first went live in Adventist's hospital in Walla Walla, Wash., in early 2007. That initiative, which has integrated all the PACS at all the hospitals into a central archive, is set to complete integration work this month.

Of course, even with a clear overall objective and a well-planned strategy, there are always tactical challenges to imaging integration, notes CTO McGovern. “You start off a project like this thinking that the primary objective is, as Alan has said, integrating the image into the primary EMR, so that doctors have one-stop shopping,” he says. “But then you realize there are competing audiences; the radiologist doesn't care so much about the EMR but about the PACS. And then you might have orthopods who are far away who just want to rummage quickly through images; or you might have teleradiology going at the same time. So your primary objective is nice, but doesn't scratch everybody's itch. We've struggled with trying to meet performance standards.”

Soderblom says they are working to meet the needs of the different types of physicians. “Once we have that issue figured out, having that single place makes it easier to work through the challenges,” he says. Soderblom, McGovern, and their colleagues have also integrated the imaging functionality around echocardiography and digital mammography into the overall architecture.

Another issue that Adventist's team has been working on, in common with the folks at Alegent and Fletcher Allen, is the looming storage issue. In the case of the unified image archive, the volume has doubled just in the past year, leaping from four terabytes to eight, with every indication it will continue at a rapid pace.

McGovern says it's no easy task. “One thing that people don't realize until they're doing it is the huge challenge of imaging management,” he says “These aren't little data bits; you're facing big imaging storage problems. So, in regard to just the basic mechanics per the size of your WAN or storage network, and the other practical issues, you just don't realize how much is involved.” In addition, he says, ensuring the proper level of staffing to support enterprise-wide imaging management is crucial.